The incident

An oiler and an engine cadet were holding the plates against the railings in the engine room, while another oiler (positioned in the middle) was trying to secure the plates to the railings, using a piece of rope. The ship rolled unexpectedly due to the large swell and the plates moved, falling on top of the oiler, partially crushing him as he tried to escape. Britannia Club suggests that the oiler was extremely fortunate as the other crew members were there to help remove the plates, but he did suffer very serious leg, arm and internal injuries.

The ship was diverted, so that the oiler could receive emergency medical treatment. He spent six weeks in hospital before his condition stabilised sufficiently to allow his repatriation home, to continue his medical treatment.

The Club says that a risk assessment and tool box talk was carried out, but were found not to have been done properly. During the risk assessment process,the risk of personal injury was identified as highly likely. Therefore the task should not have been carried out without proper consideration of the lifting arrangements. In this case, the lifting should have been carried out using chain blocks or other specialised equipment, not just with a piece of rope. Also,the lifting arrangements should have been checked by a responsible officer which did not happen in this case. The tool box talk was a tick box exercise only; the risks were not discussed and the job was not adequately supervised as per the work plan.

The master’s analysis found that the root cause was a failure of compliance with the safe practices on board. These are:

  • Crew negligence
  • Lack of concentration
  • Lack of materials and resources
  • Lack of procedure and control
  • Failure to follow procedures and instructions
  • Lack of knowledge and experience
  • Improper lifting, handling and storage
  • Improper position for task


Britannia recommends the following practices, in order to prevent shippers from similar accidents:

  • The risk assessment should be fit for purpose and should be clear to everyone involved
  • During a tool box talk the risks and actions must be discussed thoroughly with the people involved
  • The crew should be encouraged to challenge and contribute during risk assessment and tool box talks
  • Whenever possible the correct lifting equipment (such as chain blocks and cranes) should be used
  • The crew must be encouraged to use the ‘stop and think’ approach if things do not go according to plan
  • If the procedures are not effective, they should be reviewed and changed
  • Lesson learned should be shared with the fleet.